Clash in the name of care: The e-mails

Doctors raise concerns about double-booking

How can a surgeon be in more than one place at one time?

Dr. Dennis W. Burke, orthopedic surgeon

Hi, I am looking at Monday’s schedule and I see Dr. Wood booked in two rooms. OR 21 and OR 30. Are we allowing 2 rooms for major spine surgery? Did you approve this? Let me know. Thanks, Sunder

Hi Sunder

I spoke with Harry and the Kirk about this some time ago. According to Kirk and Harry, Kirk has the fellow manpower to do this. If there are issues or concerns, please let me and or Harry know. I did not have afollow up confirmation from either of them tthat they had either come to a final plan on this. I will f/u with harry to hear from him how this is goign to work from their perspective given the nature of the cases and the need to have attending oversight during much if not most of the procedure.

thanks

Peter

Do you really think it reasonable to do these two cases by the same primary surgeon? Is this how we are planning the future? I am surprised to find this out from the schedule. Sunder

Hi Dennis,

xxxxxx xxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxx xxxxxx xxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxxx

I spoke to Dave Torchiana this morning and told him of our conversation. I believe I describe the situation accurately. I certainly did not overstate it and if I conveyed anything incorrectly I apologize. I told him the situation you recounted to me suggests a problem that needs to be resolved, but that was for him to conclude not me. He said he would contact you and that he would hold all confidences.

I told him I do not plan to mention the matter to anyone else.

I respect the fact that you would discuss the matter with me and I hope the situation that exists is resolved to your satisfaction.

Regards,

Ron

Dear Ron,

You are a good friend of the hospital to take an interest in this matter. I look forward to talking privately to Torch. I assure you that my only reason for bringing this up is concern for patient’s well being and the reputation of this institution. As I mentioned, I already have had to take over the care of one patient who developed severe complications in the context of the circumstances that I expressed to you. I am aware of others.

Sometimes institutions with a hierarchical management structure like the MGH don’t look kindly upon criticism from within. Ernest Amory Codman, a surgeon at the MGH around the turn of the century, was booted off staff for having the temerity to suggest that physicians be accountable for their end results. His efforts eventually helped found what is now known as the Joint Commission on Hospital Accreditation.

I have no ax to grind in this matter. I’ll ask Torch to also talk to several of my colleagues here who have expressed similar concerns to me.

Warmest regards,

Dennis

Dear Dennis,

I spoke with Ron the other day and he mentioned some concerns you had about the OR. Do you want to talk to me sometime on the phone or in person? I will of course keep anything you say in strictest confidence in terms of your identity but if there’s something wrong I’ll need to take steps to correct it. Another alternative which is also strictly confidential is the institutional compliance hotline which can be access either through the MGH # or a PHS # depending on preference.

Thanks, Torch

Torch,

Probably best to talk to you in person — privately if you don’t mind.

Any chance that you have time next Thursday sometime? After I talk to you I will suggest that you talk to a couple of other staff who have expressed similar concerns and who would be willing to speak to you as well.

Tx,

Dennis

Dear Torch,

I have been informed that it is a stated policy position by MGH orthopaedic leadership that if a surgeon simply makes an appearance in the operating room suite and does not scrub he still can be listed as the responsible surgeon and considered “present for the critical parts of the operation.” I might suggest that you call Peter Dunn about this and then follow-up with a call to Harry Rubash.

You might ask Peter about the 8 or 9 cases of significant orthopaedic safety issues he has pending. Some are very serious, 3 deaths I believe. I’m concerned that orthopaedics is being asked to review itself and given the circumstances how meaningful that would be. Our current orthopaedic staff in charge of quality and safety recently published his experience in the NEJM about his wrong site surgery event.

Do not rely on compliance metrics. You would be better to cross reference double booked rooms with complication rates, blood loss, length of surgery etc. Look at surgeons computer log on times compared to their OR schedules.

My sense is that there is some urgency in this particuarly given the serious patient safety issues that I raised.

There is considerable “chatter” among some of the nursing and physician staff. The operating room schedules are widely distributed. I have on a number of occasions been asked: How can a surgeon be in more than one place at one time? I have no answer.

I believe this issue may have significant ramifications for the MGH and Partners. I have shared my thoughts and communications with Ron Skates.

Regards,

Dennis

Note: In the first paragraph, Dr. Burke is questioning whether surgeons have to actively participate in surgery in order to bill for it. Hospital billing guidelines for concurrent surgeries in 2002 did not list requirements for surgeons to “scrub in” to operations, but they had to be present at least for “key portions of the case.”
In the second paragraph, Dr. Burke is alluding to a cluster of safety complaints involving orthopedic surgery. Six months earlier, the hospital’s medical director of the OR had noticed “an increase in the incidence of apparent complications” in the department, MGH said.

Thanks.

I spoke with Ron.

I appreciate your attention to this and share your concern. We’ll make sure it gets straightened out, please keep me informed if it isn’t.

Torch

MGH launches internal inquiry

We know that you had specific concerns about cases that were handled in a way that you felt were not appropriate. Any documents related to those that you have would be very helpful.

Julie C. Chattopadhyay, legal counsel, Partners HealthCare

Good Morning Dr. Burke,

As you know from your conversation with Dr. Torchiana, the Office of General Counsel is conducting a review of some of the practices in MGH’s Orthopedics Department. To that end, we would like to set up an interview with you. My assistant, Sharon Boston, will be in touch with your assistant to set up a time. Thank you for your cooperation.

Julie Chattopadhyay

Dr. Burke - this is confirmed. We will meet Tuesday, July 19th at 2pm at 50 Staniford Street.

Our offices are on the 10th Floor. When you arrive, ask for me.

We would like for you to bring any documents that you think would be appropriate for us to look at. We know that you had specific concerns about cases that were handled in a way that you felt were not appropriate. Any documents related to those that you have would be very helpful. Any documents or specific examples of patient harm resulting from 2 operating rooms being run by a surgeon simultaneously would be great.

Thank you so much for taking the time out of your busy schedule to meet with us.

Julie

Dear Ms. Chattopadhyay,

Terrific- I’ll be there Tuesday at 2 PM, July 19th- 50 Staniford St.

Just a question on paper work. Some of the documents that may be relevant . e.g. surgical schedules, aren’t really patient records but they have patient info on them. Can I share these with outside counsel and hospital counsel without having a HIPPA violation situation? I understand there is a HIPPA exception for quality review and would this be applicable?

If this is a problem I can black out identifying info.

Tx,

Dennis Burke

MGH staffers allege problems during double-booked surgeries

Every day on this service is another unbelievable experience.

Dr. Lisa Wollman-Kliman, MGH anesthesiologist

Hi Wilton, Can you please review this email from Dr Warner regarding a recent case in the OR. I know this is only one side of the story & I hope we can do better. Please contact JP. thanks, Harry

“Today I did a first case which was delayed for more than 2.5 hours due to anesthesia. Issue was a patient with difficult airway. The problem was that I had 3 weeks ago personally emailed both Sunder and Richard Pino with details of this patient asking them to make staff available and let me know if anything else should be done. This was documented in LMR. Sunder emailed me back and said he was no longer in charge so it was not his responsibility and to take it up with Richard Pino. Richard Pino acknowledged receiving the email. Problem was that he did nothing. As a result no one was ready for the case and anesthesia staff had to get an ad hoc consultation from an ENT physician and then scramble to get awake fiberoptic intubation underway. Moreover, the patient was seen in PATA with all this information available and nothing was initiated here either. When I spoke with Richard he indicated yes he “dropped the ball” and was sorry about it. But there was no clear indication that it won’t happen again as he is so busy. Seems like the potential for errors is high with such an attitude. I did everything reasonable to create an efficient situation and protect my patient… and anesthesia and PATA were inept due to errors of omission by staff. Result, I performed 35 minutes of surgery by 3pm or mathematically stated, of the 5 hours of O.R. time until that point only 12% were spent actually operating. Safety report to follow but thought you’d like to hear about this one.”

Sent from my iPhone

We need to see what happened??

Sent from my iPhone

Hi All,

I have cc’d Sue on this since she was the anesthesiologist. From my understanding, the delay was not 2.5 hours.

Jon has a tendency of counting “operating time” versus actual case time. He routinely does not account for sometimes two hours of a patient anesthetized waiting for him when he is operating in two rooms and the frequent need for PM incentives to cover his rooms because of surgical delays covering two ORs. But, this is a separate issue. When I have access to the dynamic schedule upon arrival to MVH, I will check the times for accuracy.

From what I remember, I was emailed about this patient having previous laryngeal surgery. There was nothing outstanding to do other than our usual handling of a difficult airway. I did drop the ball in not informing the team about this in advance and apologized to Jon. However, I don’t feel that notifying the team in advance would have changed anything.

Here is the reality of PATA and Ortho:

1. I get inundated with relatively useless emails from PATA about patients. If a patient requires further testing, I don’t need to get cc’d on the email to the surgeon and the PCP (example, “I have contacted the PCP for further information.”) This then “kindles” further useless emails (e.g., “Thanks for doing this.”), then emails from PATA, the PCP, and the surgeon!

2. I offer opinion for those cases that are pertinent. For example, there was the recent case of a gentleman with an extremely high TSH who I suggested canceling until his thyroid function was normalized. There was another patient who required admission for a heparin gtt bridge prior to the OR.

3. I often get these emails before I know who will be assigned to the service, let alone a specific OR.

4. It is reasonable for PATA to place in the scheduling information Jehovah’s witness, female anesthesiologist only, staff anesthesia request, difficult airway, etc. The anesthesia team and staff administrators read these.

5. Surgeons usually consult other surgeons. If there was an issue with the airway secondary to cancer surgery, one of our ENT surgeons should have been consulted in advance as done on other services.

6. Ortho cases have been done throughout the OR in General Surgery, SDSU, and Ortho. Often it has been difficult to determine where these cases have been scheduled in advance.

7. Some surgeons (Freiberg, Burke) never have problems. Others have more frequent issues.

Now, here are some changes:

1. Beginning tomorrow, all Ortho will be in Lunder 3 with the exception of IORT cases for OR 43.

2. Each day there is an “administrator of the day (AOD)” who I can forward issues to. In addition, the AOD will be listed in OpenTempo. He/she will be available for consultation as needed.

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Thanks.

Dick

Peter, Just a follow-up about the problems with spine case and again two rooms by the same surgeon xxxx. Mike Cole was the scrub tech who told me about this. Susan Lien was our resident and Rehan Siddiqui was our staff. Susan Lien told me that Dr. Wood was scrubbed out for four hours and was in the other room. Susan Lien does not know about all the problems with double bookings etc. You may want to chat with all three of them. I don’t believe that anyone filed a report regarding this.

Sunder

FYI. They did not have the right instruments to take the screws out and the patient has to come back again after six hrs of surgery xxxxxx. Sunder

Peter, I am sure you had a chance to review the case mentioned. I don’t believe that safety report was filed by anyone. This was unsolicited information that came to me from OR staff who were concerned. my resident susan lien, when asked as a routine question as to how the big spine case went told me “it was horrible, the poor patient needs to come back to have another surgery”. Please let me know what is happening about this. I need to respond the staff who came to me and I also want to make sure that I am doing the right thing. The events in the last few days have escalated my concerns about patient safety and process in place to sort them out. Thanks, Sunder

Hi Sunder

I spoke with David Ring and asked him to look into this for ortho QA. Lisa is following up with Mike Vile as she heard nothing about this from the ortho nursing team when I asked her. I had to leave MGH earlier xxx because of family issues do plan to follow up with Rehan and Susan Monday AM

Thanks

Peter

Sent from my iPhone

Peter,

thanks for your reply. I shall look forward to your analysis of the spine cases from last week. Lot of the staff do not know what to do when they witness something like this. I am enclosing an article that you may find interesting especially given the current environment. I knew this resident and have been following this story for a few years.

Thanks,

Sunder

Hi Sunder

I have filed the saftey report and have asked John Belknap to review the 2 cases.

Thanks

Peter

Just wanted to let you know that I was covering OR 70 xxxx — one of the trauma rooms; the first patient xxx xx xxxxxxxx xxx had some horrific experience at MGH many years ago… who asked that only surgical and anesthesia attendings actually do the procedures planned. As this put a glitch in the plans for Dr. Smith to be in two places, the conversation that took place in the preop bay was quite remarkable. The patient was told that she was manipulating the system thereby setting herself up for complications and that she was now going to be indefinitely delayed.

The patient was reduced to tears, started to have a full blown panic attack, at which point her PCP and I had to intervene and assure her that she had not "pissed off her surgeon" and that she would not be delayed more than an hour or two… and that she would get her wish of attendings in the room at all times.

Every day on this service is another unbelievable experience…

Lisa

xxxx I was put in a situation which has become common place on the ortho service but which I believe is unacceptable for both safety and ethical reasons. As I have written about before, and talked at length with Don Stern and his team, I was asked to provide anesthesia for one of the two rooms booked for Dr. Warner. As we rolled into the room, the patient asked where Dr. Warner was so I checked in his other room, I found that patient asleep and being positioned. Dr. Warner’s fellow informed me that Dr. Warner was in clinic in the Yawkey building seeing patients.

I asked that Dr. Warner be paged to come to the room so that our patient could see him and so I would know that he was in fact, immediately available. He came to the room right away but was livid that I had not put the patient to sleep and that I had an issue with his whereabouts…

The patient went to sleep right away and the case proceeded without incident — other than some inappropriate harassment form Dr. Warner about my lack of understanding of physiology and shoulder perfusion.

I know that as was discussed this xxxxxxx, there are many issues to be addressed in the anesthesia and surgical departments; however, this issue of surgeon availability and presence in the OR is not something that can wait for a committee to resolve or can be ignored. Patients deserve honesty and the surgical and anesthesia team should not be asked to participate in the deception that the surgeon is present for the “critical parts” of the case.

I am aware of at least one and possibly several cases where this same surgeon never scrubbed into the case; xx xxx xxxxxxxxxx xxxx, xxx xxxxxxx xxx xxx xxxx xx x xxxxxxx xxx xxxx xxxx xxx xxxx xxxxx xxxxxxxxxxxx xxx xx. xxxxxx’x xxxxxxxx xxxxxxxxx.

I am not sure of the best way for this to be handled in the moment with patient care being the priority; it would useful to have some conversation with hospital administration outside of the operating room. The results of the internal inquiry by Mr. Stern have not been shared with all of us who participated although it is well known that my grievances are shared by many… most of whom do not feel empowered to speak up.

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Lisa Wollman, MD

Note: Donald Stern is a former US Attorney hired by Mass. General to investigate concurrent surgery.

Thanks for your comments today and this feedback. Attending surgeons, including JP, are obligated to be present for the critical parts of their cases — concern about this issue was the reason that Don Stern was asked to undertake the review which has been completed. The report was prepared via an interview process that I realize you were involved in. The participants were promised confidentiality which means that the report will not be broadly circulated but the recommendations will be implemented. In the meantime, if you are concerned that the rules are being breached, please notify the compliance office, your anonymity is guaranteed.

On the compensation front that you raised this morning, the data show that the average and median compensation in MGH anesthesia have increased by a little over 50% in the last eight years that you referenced and the department as a whole went from being paid at the 56th percentile vs national benchmarks to the 63rd percentile. Compensation is complicated in any specialty and I am sure equally so in anesthesia with base salary, various stipends and evening incentives so the average picture isn’t the true picture for everyone which may be what impacts your perception.

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Torch

Dear Kelsey,

Thank you for the follow-up.

1) MRXXXXXX

With respect to the first ETC02 issue —

This patient was scheduled for an uncomplicated shoulder replacement. However, he suffered a major vascular complication while Dr. Warner was operating. This arterial laceration required emergent exploration and repair; I called Dr. Virendra Patel myself and facilitated his arrival. The patient lost 1300 milliliters of blood. The orthopedic surgery was aborted and the patient has not returned to the MGH for the definitive operation. We did contact the engineers for assistance with the Belmont Rapid transfusion system and radiology equipment. The engineers adapted electrical plugs for these additional devices and repositioned the immobile boom for proper access to the patient.

Dr. Warner was scheduled to operate in OR 66 as well. Of note, the patient in OR 66 was anesthetized for over one and a half hours without the primary attending surgeon present. Perhaps this situation should be addressed in the Physician Performance Arena (OPPE), the MGH Safety Committee and the Surgical Steering Committee. This series of events could confirm what we know — that double booking by surgeons (i.e. in more than one room simultaneously) is unwise and potentially injurious to patients. Should I contact these resources to be certain that this unfortunate event does not recur?

xxx xxx xxxxxxx x xxxxx x xxx x xxxxx x xxx xxxxxxx

Susan

Note: Dr. Virendra Patel is a vascular surgeon.

The Stern report completed, not released

It is my understanding that the MGH has taken your concerns very seriously.

Dr. Michael Jellinek, chief of clinical affairs for Partners HealthCare

Dear Julie,

Dr. Torchiana called me earlier in the week and told me That Don Stern’s report has been completed. We briefly talked about it. As you know from my previous email I am concerned about my reporting responsibilities to outside authorities regarding the subject of his report. You suggested that I wait until the report is completed and I have done that.

How might I view Mr. Stern’s report so as to make an informed decision about my reporting responsibilities? I would again request guidance form Partners Office of General Counsel about my responsibility. If Partners OGC feels unable to advise me on this matter I will request a meeting with Dr. Gottlieb and Mr. Brent Henry to discuss this matter.

I don’t want to have a Joe Paterno/Penn State situation here. When patients come to the MGH they have certain expectations about the care that they will get. All I want is that we provide the care to all our patients that you, I or anyone would want for themselves or a family member.

Regards,

Dennis

Dear Dr. Burke,

Thank you for your email. I appreciate your concerns. As you are aware, MGH is treating the issues that you raised very seriously and has done so all along. Regarding Mr. Stern’s review and report to the institution, any communications between the institution and legal counsel are protected by the attorney client privilege. Legally, discussing the details of Mr. Stern’s report with anyone other than the client could consitute a waiver of that privilege. This would not be prudent or appropriate. This review was done under attorney client privilege for the purposes of obtaining legal advice. Further, as is the case with a peer review, the process was designed to give maximum confidentiality and protection to those who were interviewed, and to the institution, in an effort to get complete candor and have as thorough and complete a review as possible. MGH is developing an appropriate response to the issues involved, based on Mr. Stern’s review and recommendations. Dr. Torchiana will reach out to you once a specific action plan is fully developed.

As for the reporting concerns you raise, I previously explained in my 8/30/11 email to you that OGC is not able to advise you. What I can tell you, however, is that this is not at all a Joe Paterno/Penn State situation. You raised concerns and MGH heard them loud and clear, took them very seriously, took action and is responding accordingly. Based on what we learned through our investigation, we do not believe that MGH has reporting obligations here. At the same time, MGH feels strongly about its obligation to make sure that its patients get the best care, and intends to do what is appropriate, with the help of Mr. Stern’s review and findings, to ensure that.

Again, thank you for raising your concerns.

Julie

Dear Ann,

With the Stern Report completed, I am distressed that the unsafe practice of allowing attending surgeons to operate in multiple rooms simultaneously has not been curtailed.

xxx xxxxxxx xxxx xxxx xx xxx xxxxxxx xxxxxxxxx xxx xxxxxxxxx xxxxxxxxxx xxx xxxxxxx xxxxxxx xxxxxxxx xxxxxxxxxxxx xxx xxxxxxxx xx xxx xxxxxxx xx xxx xxxxxxxxx xxxxxxx xxxxxxxxx xx xxx xxxxx xxxxxxxxxxxxxx

Recently, local and national press criticized in the harshest way, the orthopaedic surgical care received by a major sports figure at the MGH. One headline called it, “botched back surgery.” Can you imagine the harm that will occur to this institution’s reputation if it were to be discovered that this patient’s surgery was “double booked,” with the attending surgeon operating on two patients simultaneously? Please look into it.

xxx xxxxxxx xxxx xxxx xx xxx xxxxxxx xxxxxxxxx xxx xxxxxxxxx xxxxxxxxxx xxx xxxxxxx xxxxxxx xxxxxxxx xxxxxxxxxxxx xxx xxxxxxxx xx xxx xxxxxxx xx xxx xxxxxxxxx xxxxxxx xxxxxxxxx xx xxx xxxxx xxxxxxxxxxxxxx xx xxx xxxxxxx xx xxx xxxxxxxxx xxxxxxx xxxxxxxxx xx xxx xxxxx xxxxxxxxxxxxxx

When I last wrote you concerning these issues, you called them “challenges.” These are not challenges but human being who surrender themselves to us utterly when they come to the MGH for surgical care. The most important asset we have is trust. We can never allow that trust to be broken.

It appears to me that this institution has been unable to effectively deal with this problem. I am requesting to meet with Dr. Gary Gottlieb and Ms. Cathy Minehan to explain my concerns. I am asking your assistance in setting this up. I will be leaving March 21st on a medical mission to the Dominican Republic. Given the serious and ongoing nature of this problem, I would hope to meet before then. I will make myself available at their convenience.

I know how much you care about patient safety and the MGH. I look forward to hearing from you.

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Sincerely,

Dennis

Dear Dennis,

Please know that we all put patient safety as our highest priority. The policy for working out of two rooms is in the process of revision under the leadership of Dr. Lillemoe, our new Surgeon-in-Chief. We hope to have this completed very soon. I suggest that an internal meeting among all of us might be most constructive vs. a meeting with Dr. Gottlieb and Ms. Minehan as a next step. If you agree, I am happy to arrange.

Thank you,

Ann

Dear Peter and Torch,

I want to thank you for meeting with me this past Thursday and allowing me to express my concerns over patient safety issues on the orthopaedic service at MGH. The issue we discussed is the practice of surgeons being allowed to operate in multiple rooms at the same time. In my opinion, based on experience, this practice is unsafe and unwise.

That conclusion came into sharp focus for me in 2008 when I assumed the care of an elderly woman who developed severe postoperative complications. Her surgery was done mostly by unsupervised residents. The resident performing the operation asked for help not once, not twice but three times before the reluctant attending surgeon made an appearance, and then only after an anesthetist physically went to the other room where he was operating and insisted. I complained to my Chairman, Dr. Harry Rubash about this. The resident was faulted. Both of you have heard this story before but to emphasize just how bad her care was I am attaching her postoperative x-ray. It says it all.

In July 2010, at a meeting attended by Dr. Jeanine Weiner-Kronish, Chief of MGH Anesthesia and Dr. Peter Dunn, director of our operating rooms, I made it clear that this unsafe practice should stop. I warned about grave consequences if it did not. Some weeks later a 93 year woman undergoing an elective hip replacement bled to death the evening of surgery. Her surgeon had two major elective cases going on at the same time.

You have been given examples of vascular and neurologic injuries in the context of surgeons running between two or more rooms. I gave you an operating room schedule where a single surgeon was operating in 3 rooms at essentially the same time. Records have been falsified to make it appear that a surgeon performed an operation when he did not scrub or even appear in the operating room. The statement that complications occurring in this context are unrelated to the attending surgeon’s absence for all or part of the surgery is not credible. The statement that other academic institutions allow it leaves me unfulfilled. Peter — you told me that I have a minority view on this subject. I reject that out of hand. I would ask you how many patients’ opinion did you seek?

At a Department of Orthopaedic Surgery staff meeting in April of 2011 it was announced, as if a revelation, that surgeons would have to scrub for “the critical part of the operation.” I gave an example of a severe complication in the context of double booked rooms and complained loudly about this practice. I asked our Chairman what the definition of the critical part of an operation was. He said there is none. He said the practice of surgeons running multiple rooms will continue.

I am not alone in my concerns. I am attaching emails from other colleagues. Dr. Dick Pino, Vice-Chair of Anesthesia wrote to Dr. Jeanine Weiner-Kronish, that patients are routinely anesthetized unnecessarily for two hours while they wait for the attending surgeon who is operating elsewhere. He commented that frequent staff overtime is needed to cover those surgical delays. This bolsters my contention that double booking rooms is a false economy. Dr. Neelakantan Sunder, one of our most respected senior anesthesia staff met with chief compliance officer John Belknap on December 6th and gave him specific examples why double booking is such a bad idea. He expressed the concerns that some staff have over retaliation for speaking out. Dr. Lisa Wollman, a staff anesthetist, wrote to Anne Prestipino, Vice-President of Surgical Services that this practice was “appalling and scandalous” and “potentially fraudulent.” She was simply rotated off this particular surgeon’s schedule. Senior staff anesthetists feel that they are being marginalized for complaining about patient safety.

In an effort to push volume, the operating room environment has become uncivil. As an example, staff anesthetist Dr. Margaret Gargarian, was brought to the point of tears by a surgeon dissatisfied with the speed with which she administered a spinal. She emailed her supervisor that she felt treated in a “threatening” and “demeaning” manner. It was suggested that if she couldn’t speed it up, orthopaedics might not be the place for her. A resident was treated in a similar fashion. Their complaints were essentially ignored. This practice of branding physicians who raise legitimate safety concerns as trouble makers and suggesting they leave or are moved elsewhere is appalling. It is a culture of anti-safety and a prescription for disaster. I made it clear to you how strongly I feel about this.

I left our meeting totally dissatisfied that meaningful change will occur. What I heard is that double booking will continue. The only difference is that there will be more disclosure to patients about this practice and that rules for attendance by a surgeon in the operating room will be strengthened. You cannot disclose away patient’s rights. Patients come to us vulnerable, often disabled, sick or injured. What position are they in to refuse care under almost any circumstance? Dr. Lisa Wollman’s email of November 21 brings this point home loud and clear. A patient was “reduced to tears” for insisting that her surgeon, who had been double booked, be attentive only to her during the period of her operation. Is that really too much to ask? Another patient that I am aware of asked to see her surgeon before entering the operating room. This requested was not honored. By one account she was “coerced” into to operating room. When she overheard from OR personal that her surgeon would be operating in two rooms simultaneously she became agitated, called it a “scam” and insisted on being removed from the OR. I asked both of you if you would allow a family member to be operated on under this circumstance. I heard only silence.

Stricter rules alone will have little effect. The assumption that a surgeon’s responsibility is met if he or she is merely present for the “critical part” of the operation is a ruse when a surgeon is allowed to self define what “critical part” means. I have heard that some surgeons consider the critical part is satisfied simply by entering an operating room or preoperative holding area without even scrubbing. What we really need is to re-establish professional ethics, integrity and honor the trust that patients place in us and this institution.

Attorney Donald Stern’s investigation was commissioned by Partners Healthcare to look into the allegations of poor patient care associated with the practice of double booked surgical rooms. It took six months to complete. You mentioned he interviewed 50 MGH staff. I found it particuarly disappointing that you would not discuss the contents or conclusions of the Stern Report whatsoever. What struck me as almost not believable is that Dr. Keith Lillemoe, Surgeon-in-Chief at the MGH, who is in charge of correcting this problem, has not been allowed to see it. I hope you understand that to some this will have the appearance of an institutional cover-up.

Finally, I would like to say that I do not doubt your commitment to patient safety one bit but we do have a fundamental difference of opinion on what needs to be done to fix this problem. Inaction, at multiple levels within this institution, has and continues to jeopardize patient safety. As such, and with all due respect, I feel compelled to bring this issue to the attention of Dean Cathy Minehan, Chairman of the Board of Trustees of MGH and Dr. Gary Gottlieb, Partners CEO.

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Sincerely yours,

Dennis Burke, M.D.

Dear Gary,

The correspondences that I have attached, together with the email I sent you yesterday pretty much sums up my concerns about patient safety on the Orthopaedic Service at MGH. I am sorry to have to bring this to your attention but it is a serious issue that not only affects patient care but also the reputation of the MGH and Partners.

From my point of view, with rare exception, it makes no sense whatsoever for a surgeon to try to be in two places at the same time.

The solution outlined to me — better patient disclosure and tightened attendance rules for surgeons, in my opinion — is not the answer. We as professionals need to treat patients as we ourselves would want to be treated.

I would very much appreciate the opportunity to meet with you privately about this. I have also made this request to Dean Cathy Minehan. I would be happy to meet with you jointly. I will make myself available at your convenience.

Sincerely yours,

Dennis

Dear Dennis,

Thank you so much for your email.

I understand that MGH has obtained a detailed outside review of the concerns you raised, and based on this review, will be implementing changes in certain of its polices and practices. I also understand that you have met with Drs. Torchiana and Slavin and had the opportunity to express your views regarding this proposed course of action.

At this point in time, I do not believe that my involvement in the matter would serve a useful purpose.

Best,

Gary

Dear Mike,

I am asking you to look at the attached correspondences in your capacity as Chief of Clinical Affairs for Partners Healthcare. I think they are self explanatory. I’m not sure if you have heard about this situation. Some time ago I became concerned that surgical complications appeared to be associated with the practice of surgeons operating in multiple rooms at the same time. It seems to be mostly an orthopaedic problem and only a minority of surgeons engage in it. I’ve gone stepwise up the hospital chain of command trying to point out the problem with this but have not had much luck changing things.

With pressure from Ron Skates, Partners Healthcare hired attorney Donald Stern to do a pretty exhaustive internal investigation. His report has been kept Top Secret.

I see a huge liability to MGH and Partners if something isn’t done pretty soon to fix it. I think bold action is necessary. As an example, just look at one small aspect of this problem. Patients are sometimes kept anesthetized, lying fallow for prolonged periods of time, while their surgeon is operating elsewhere. The added cost and more importantly, morbidity to the patient, cannot be justified. A few years ago, one of our errant former residents left his operating room at the Mt. Auburn Hospital for mere 20 minutes to cash a check. When this became public it was a disaster, making national headlines. What has been going on here seems far worse.

The rumor around the hospital is that if this practice is curtailed some high volume surgeons will take patients elsewhere. There can be little question that economics is a significant factor and that is too bad.

I have requested a meeting with Dr. Gary Gottlieb and Dean Cathy Minehan to explain my concerns. I would appreciate anything you could do to facilitate this. Perhaps you might want to attend.

It is important that you understand that this is not about criticizing any of my colleagues. They are talented and hardworking. To me this is about recognizing that our emphasis in MGH orthopaedics has changed from quality to production and that we must get back on course.

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Regards,

Dennis

Thank you for your emails and for sharing your concerns with me. As you know I have great respect for you and have considered this carefully. I have come to the conclusion that these matters are best addressed and will be addressed by the senior leadership at MGH. It is my understanding that the MGH has taken your concerns very seriously. They engaged Attorney Stern to conduct an outside review of the issues you raised, and are in the process of implementing changes in policies and procedures based on this review. In light of this, I don’t believe that my involvement would be beneficial.

Mike

MGH unveils revised concurrent surgery policy

I just cannot believe that this is the official policy of the MGH.

Dr. Neelakantan Sunder, anesthesiologist

Keith Lillemoe is coming to our staff meeting tomorrow (Thursday 6/7/2012 at 6:45 AM) to talk about the double booking policy at MGH. I’ve attached the new policy that is being proposed.

unbelievable!

“Attending surgeon may not perform or be present in the room for the entire case, however, will be immediately available or have another surgeon available.”

I just cannot believe that this is the official policy at the MGH.

Dear Peter, Torch and Harry,

Dr. Keith Lillemoe presented to the Orthopaedic Department this past Thursday the revised MGH Policy: Criteria for Concurrent Staffing of Two Operating Rooms. This policy was developed in response to the Donald Stern investigation. I am disappointed that it fails to protect patients, in any meaningful way, from the abuses that occurred under the old policy (see attached pdf file, Burke to Chattopadhyay 8-15-2011). While surgeons can no longer run three rooms simultaneously under the new policy they still can “operate” on two patients at the same time. Surgeons, while required to be present for the “critical part” of surgery, self define “critical part.” Surgeons are not required to be in attendance while their patient is being operated on as long as they are “immediately available.” According to the policy “immediately available” is so broadly defined that the responsible surgeon may be over a quarter mile away. Disclosure of these practices to patients is optional at the surgeon’s discretion under this policy.

The opening sentence of the policy states that it was designed to, “ensure the highest quality and safest care for all patients undergoing an operation at the MGH.” This statement is dishonest. We can debate the ethical, moral and legal aspects of surgeons operating in multiple rooms simultaneously but there can be little argument that it does not represent the, “highest quality and safest care.” Patients are being deceived when their surgeon allows physicians in training to perform major parts of their operation without direct supervision. We as surgeons and as an institution are handsomely paid for the services we provide. Is it really too much to ask that we show up?

This policy fails at a very basic level to meet the standard of care that we at MGH so proudly advertise to our patients. Torch, you yourself publicly boasted that, “We take care of one patient at a time and always try to give them our best.” Not true according this policy.

This document has been constructed for the economic benefit of surgeons and this hospital with little regard for patient’s best interests. At a recent meeting between Dr. Lillemoe and two of my colleagues, he candidly told us of his strong personal opposition to these practices but admitted the hospital will not allow them to be stopped out of concern that some high volume surgeons engaged in these practices will bring their patients elsewhere. It is fee for service run amok.

There has been no transparency in the development of this policy. Even the existence of the Stern Investigation has been tightly held. Its findings are essentially top secret. There needs to be open discussion among staff physicians, ethicists, patient safety experts and patient advocates as to the findings of the Stern investigation and then construct a policy that truly promotes best surgical practices. Many of my colleagues agree with me on this but are reluctant to speak up. Those who have are branded as troublemakers.

Later today I will perform major surgery on a woman with an arthritic hip. Her 92 year old husband, a former RAF Spitfire pilot and also a patient of mine, wrote me this email below over the weekend. His request, his expectation, his hope is that I and this institution give his beloved xxxxxxx the best care we can. This policy fails him, his wife, our profession and this institution’s high standards. As justification, I have been told that other institutions engage in these practices. The MGH should be about leading, not following. We can do better.

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Respectfully,

Dennis

Note: Dr. Keith Lillemoe describes MGH’s policy as “among the most comprehensive and well-defined in the country,” and the hospital says its own experts and analysis have found that concurrent surgery is safe. The American College of Surgeons reviewed the guidelines at the hospital’s request and deemed them an “example of best practice and certainly exceed national standards.”

Dear Mike,

The following is FYI. I understand that you cannot respond back.

Next time you are on Charles street take a brisk walk from the Lunder Building lobby to the Sports Medicine offices in Charles River Park and time it. Calculate the how long it would take to page someone and respond, change in to scrubs, wash and gown and add that. Then ask yourself if you or a family members were undergoing major surgery if that far and long away would be OK with you for your “responsible” surgeon to be.

You looked good last night on the big screen. I like Jack’s prescription — think bold.

I appreciate everything that you are doing.

Best,

Dennis

Complaints filed with state regulators after tragic outcome

… for the first time we actually have a policy, and although it may not meet the standards that you might have wanted it is a first step out of the wild, wild west.

Dr. Keith D. Lillemoe, chief of surgery

Dear Peter, Torch and Harry,

On August xxx 2012, a 41 year old man underwent an elective cervical spine operation at the Massachusetts General Hospital. He was found to be quadriplegic in the recovery room. It was a long procedure lasting over10 hours. On the same day, during the same hours, another patient concurrently underwent a 7 hour major spinal procedure by the same surgeon. By my account, the unaccredited fellow that was acting as the “attending surgeon” in one of the cases was on the job all of 5 days. Both patients had unexpected returns to the operating room to deal with complications.

This is the latest example representing a pattern of surgical complications that have occurred when a surgeon tries to be in two places at the same time. This is the worst possible care at an institution that advertises itself as the nation’s best hospital.

I and other MGH staff members have complained to you and others about this practice repeatedly over the past several years. We have provided documentation of multiple patients who have been injured under similar circumstances to you and Attorney Donald Stern, to no avail. Not only do these practices continue but they are condoned by the revised, MGH Policy: Criteria for Concurrent Staffing of Two Operating Rooms. Double booking of surgical rooms is still encouraged in our department.

Just one week after this paralysis happened, a staff anesthetist assigned to cover a similar case that was “double booked” was so troubled by the circumstances of the week before that she called the director of the operating rooms and her department vice-chairman at home the night before the scheduled surgery. Her concerns were rebuffed and she was told that there was no problem with this surgeon double booking cases because he was in compliance according to the MGH Policy: Criteria for Concurrent Staffing of Two Operating Rooms. This is a scam that deceives patients who come to the MGH and place their trust and lives in our hands. This “switch and bait” tactic of having physicians in training perform all or major portions of surgery without the attending surgeon’s direct supervision is deceitful. No patient would allow it if they knew.

In my opinion, this practice is unethical and unsafe. It occurs frequently enough and is associated with injuries of such severity that it rises to the level of a public health hazard. It represents a clear and present danger to patient safety. As such and with great reluctance, only after having exhausted all institutional avenues of redress, I feel compelled to bring this matter to the attention of appropriate outside regulatory authorities.

This is not meant to be a criticism of any particular surgeon or their competence. I take issue with an unsound hospital policy that puts the bottom line above best practices.

What will you tell this quadriplegic man and his family when they ask if his paralysis could have been prevented by having his surgeon be attentive only to him during his surgery? Was that really too much too expect?

Not one more patient should be unnecessarily harmed. Shut this practice down.

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Sincerely yours,

Dennis W. Burke, M.D.

Note: Dr. Burke wrote this email after hearing about the Tony Meng case in 2012. Hospital attorneys said paralysis was a known risk of this surgery and Wood broke no rules and acted within the accepted standard of care. MGH said the fellow assisting in the other room was fully qualified as an attending physician. The hospital said Donald Stern, the lawyer it hired, found no support for Burke’s allegations in 2012, and an analysis of hundreds of orthopedic surgeries in 2013 and 2014 found “no significant difference” in complication rates between non-overlapping and overlapping surgeries. Read the full story.

Dear Mike,

For the love of God, sit down with Gary and figure out how to stop this.

This man is 41 years old - a quad for life. What are people thinking?

So sorry but I have to do this.

Dennis

Re: Unsafe Surgical Practices at the Massachusetts General Hospital

Dear Dr. Biondolillo,

By way of introduction, I am an orthopaedic surgeon who has been in practice at the Massachusetts General Hospital for 30 years.

It has come to my attention, through direct observation and from discussions with my colleagues at the Massachusetts General Hospital, that unsafe surgical practices are being engaged in. Specifically, some surgeons are scheduling multiple surgeries simultaneously, allowing unsupervised physicians in training to perform parts or all of the procedures. Patients are by and large unaware as to the extent and nature of these practices. Significant complications appear to be associated with these inattentive surgeons. I and others have voiced concern to hospital leadership to no avail. Attorney Donald Stern was employed by the hospital to investigate these complaints. He interviewed 50 MGH staff personal over a 6 month period. His report was completed in December of 2011 and has been kept top secret. The enclosed documents and correspondences to hospital leadership convey my concerns.

This is not meant to be a criticism of any particular surgeon or their competence. I take issue with an unsound hospital policy that puts the bottom line above best practices.

Dear Keith,

I spoke to John Potts earlier today. He told me that he filled you in with the recent conversation that he and I had.

I fully understand the desire to work within the system to effect change but I am afraid that time has passed. A recent case of quadriplegia after an elective cervical spine case settled that for me. The letter I am attaching, which I sent to Peter Slavin, David Torchiana and Harry Rubash last week, explains the situation. Even after this event, ortho and anesthesia leadership has decided to allow these double booked spine cases to continue. I just do not know what they can be thinking?

John suggested a meeting between you, he and I. I would be happy of course to do this if you like.

Warm regards,

Dennis

I had seem your letter. It is a tragic outcome that needs to be very closely looked at. I would like to meet with you this week but my schedule is pretty tight. How would 5 pm on Wednesday work. Other than that maybe Friday

Sent from my iPhone

Keith,

Thanks for your reply. As tragic as this recent paralysis case is, it is important to focus on the root problem here, not just not another bad outcome. This is not about any particular surgeon or case. It is about leadership who just don’t get it. I just do not understand where this concept of surgeons trying to be in two places at the same time came from. We have all had instances where the better good was served by us breaking scrub on a case and helping a colleague in trouble. What is happening here is different. We have produced a policy that is calculated to produce inferior care for the sake of economic gain.

I flew back from San Francisco yesterday. If I thought for a moment that the pilot would not be fully attentive during the flight I would never have gotten on. Sure, he has a co-pilot, maybe a navigator and a lot of ground help but he is responsible for my life and always there. A surgeon’s responsibility is just the same. There was a case on the Ortho service where the “attending of record” was actually in a different ZIP code when his patient was being operated on. Can you believe that? Other cases where the attending never scrubs. These practices not only result in poor patient care but diminishes out profession.

If you think that a meeting between us will be productive I would be happy to attend but it is clear to me that there is no institutional will to change. I’m convinced that any internal efforts will be fruitless.

Dennis

Sent from my iPhone

I disagree that internal efforts are fruitless. For example for the first time we actually have a policy, and although it may not meet the standards that you might have wanted it is a first step out of the wild, wild west. If you can provide evidence to me that an attending surgeon is not in the city when a case was performed and there was no covering attending, I will personally investigate and deal with it. We do have an opportunity to set the “will” of the institution, as without surgeons with the right views as to patient care, we have no institution. On the other hand, we have to avoid the extremes of both sides of the question. I hope we can find a time this week, as I am gone next week.

Dear Keith,

John Potts thought I should keep you in the loop about my reporting to outside authorities. I’ve sent formal complaints to the Department of Public Health and to the Massachusetts Board of Registration In Medicine about the double booking situation.

I did this only after a lot of soul searching. I am convinced that nothing will change unless outside pressure is brought top bear. I know you think that the revised policy on concurrent surgery improves on what we had but in some ways it makes it only worse. After that paralysis case, one of our most respected senior anesthesiologist complained to top OR administrators about a similar scenario that she was scheduled to be involved in the week after. Her supervisors used the MGH Policy on Concurrent Surgery as justification for allowing it. It is as if common sense and good judgment has been replaced by hospital regulations.

I heard through the grape vine last week, that double booking by surgeons will no longer be allowed in orthopaedics. I hope that this is true and that it represents a realization by Department and Hospital administrators that the concurrency policy was penny wise and pound foolish. Based on what I have seen it the past, I hope it is not just a cynical attempt to make things look good in the short term until things quiet down.

We need a sea change by leadership in what constitutes best surgical practices.

Regards,

Dennis

I am disappointed that you felt the need to take this to an outside authority as I am confident that changes internally are in place that could deal with the problems.

In terms of the grape vine, it is not correct. However due to violation of the policy that you feel is not going to make any difference, the spine surgeon involved in the case, has lost this privilege. In other words, not following the policy has lead to an appropriate punishment. To me that is what we were hoping to accomplish. I wish you would have given us a chance as once people see we mean business, things will change for the better. Double booking is fine, if done properly, and our policy will change the practice at the MGH.

Sent from my iPad

Dear Dr. Burke:

We have received your letter dated September 5, 2012 regarding concerns regarding unsafe surgical practices at Massachusetts General Hospital, specifically with scheduling multiple surgeries and allowing unsupervised physicians in training.

During our conversation on 9/14/12, you stated that you could not provide the Department with specific names of clinicians or patients based on patient privacy laws. You requested that I pursue getting a copy of the Stern report.

I have spoken with the Massachusetts General Administrative staff who has informed me that the report is not available based on Attorney Client privilege.

Unfortunately, without specific information regarding dates or information on the cases, the Department will not be able to conduct an investigation.

We thank you for taking the time to make your concerns known to the Department. We will place this letter on file and monitor for similar cases that are reported.

MGH fires whistleblower

Your actions have been extraordinarily disruptive to the orthopaedic surgery department.

Dr. Peter Slavin, MGH president

Dear Gerry,

I first started working at MGH when I was 15 years old. I did hearing tests in the evenings at The Bunker Hill Health Center. We met a few years later. One Saturday morning you gave me a tour of the cardiac surgical unit where I saw my first post op patient. He had, what seemed to me, a mile long chest incision. We talked. You showed a genuine interest in me. You wrote a letter on my behalf to MIT. I was accepted and my life was changed forever.

Writing this letter is very difficult.

Yesterday morning you made it quite clear how upset you were at me because The Boston Globe is making inquiries of the concurrent surgery practices at the MGH. The hospital has no one to blame but itself.

It was the disclosure about these practices at the recent gender discrimination trial that brought this issue to a public forum. It is all in the transcripts. Hospital attorneys argued in opening statements that the trial was about patient safety. Testimony suggested otherwise. You cannot have it both ways.

The hospital administration had many chances to avoid this problem but instead chose the path of institutional authority over transparency. The findings of the Stern Report were never disclosed. This will be viewed as a cover-up. Those who raise questions of patient safety fear retaliation or are marginalized and bullied. Two of our very best staff physicians have recently resigned over this.

A physician must put his patient’s interest above his own. A surgeon trying to operate on two patients at the same time serves neither well. Those who put their absolute trust in us are being deceived and put at increased risk of harm, all for economic gain.

I have spent my entire professional career at MGH, striving to provide the best possible care to patients and be an example to our surgical house staff. Our hospital has become too much about quantity, not quality. We have forgotten who we serve.

Yesterday morning you told me that I will never be forgiven. The hospital and I will be judged on the facts. But when the facts do come out, will the patients forgive those who stood by and allowed this to happen?

Sincerely yours,

Dennis

Dear Dr. Burke:

I am writing with reference to Section 6.04 of the Bylaws of the Professional Staff of the General Hospital to inform you that I am summarily terminating your privileges at Massachusetts General Hospital.

You have admitted that you provided 499 Hospital patient records to The Boston Globe. In doing so you violated Hospital policy and your signed confidentiality agreement with the Hospital.

You state that you provided the newspaper those Hospital records without maintaining copies of the records you disclosed. You have thus deprived the Hospital of the opportunity to analyze the extent of your confidentiality breach, including possible violations of HIPAA. You have exposed the Hospital to potential liability, and you have left the Hospital with no choice but to treat the disclosure as a HIPAA breach and to report it to the Department of Health and Human Service Office of Civil Rights and to the affected patients (to the extent the Hospital is able to identify them).

You have otherwise not been fully cooperative with the Hospital’s legally required efforts to determine the nature and extent of your disclosures. Your meaningful cooperation in the Hospital’s inquiry and investigation is a fundamental obligation of your privileges at the Hospital.

The Globe has informed the Hospital that you additionally provided it with confidential information concerning at least one orthopaedic surgery morbidity and mortality conference. Confidentiality is essential at M&M conference to ensure the free flow of opinions and to maintain the peer-review privilege, necessary for providing safe patient care. You and your lawyers deny having shared such information with The Globe; however, the denials, especially in the context of your admitted disclosure of hundreds of patient records and the claim that you did not keep track of your disclosures, are not credible.

Your actions have been extraordinarily disruptive to the orthopaedic surgery department. Staff members are extremely worried about the security of their communications and opinions and, as a result, there are significant concerns about participating in M&M. The department has been forced to suspend M&M conferences because of your conduct.

I am taking this summary action to restore the integrity of Hospital standards, operations, and patient care. Your lawyer has alleged that the Hospital has chosen to take this action because you raised concerns with the press and with others regarding the Hospital’s surgical scheduling practices. That allegation is without factual basis, and is wrongful. You have always been free to express your opinions within, and outside, the Hospital. Indeed, as you well know, the Hospital encourages, and expects, free and honest dialogue concerning patient care. Your actions have damaged, not promoted, that mission. It was not appropriate to hand out volumes of patient records and share confidential peer review and patient information. These are the reasons for the action today.

In order to facilitate the care and transition of patients under your care, your operating privileges will terminate effective two weeks from today, August 26. Your privileges to see inpatients will terminate four weeks from today, September 9. The Hospital expects that you will comply with your confidentiality agreement, Hospital policy, and applicable law, and it will monitor your access to the Hospital’s information systems during your transition. Maintenance of your privileges over the next month is contingent upon your complying with all Hospital rules and policies, including your confidentiality agreement.

During this four-week transition period, you will have no access to departmental meetings or conferences.

I have asked the orthopaedic surgery administration to work with you to plan for a responsible transition for your patients.

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The Stern report completed, not released

The Stern report completed, not released

MGH unveils revised concurrent surgery policy

MGH unveils revised concurrent surgery policy

Complaints filed with state regulators after tragic outcome

Complaints filed with state regulators after tragic outcome

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MGH fires whistleblower

Clash in the name of care

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